Provider Demographics
NPI:1043276504
Name:BOGDAN, JULIE D (PA)
Entity type:Individual
Prefix:DR
First Name:JULIE
Middle Name:D
Last Name:BOGDAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 OZONA RD
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-7819
Mailing Address - Country:US
Mailing Address - Phone:601-749-1502
Mailing Address - Fax:
Practice Address - Street 1:341 OZONA RD
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-7819
Practice Address - Country:US
Practice Address - Phone:601-749-1502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.A10440.RX363AM0700X
MSPA00227363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1628603Medicaid
MSPA00227Medicaid
LA56629P503Medicare ID - Type Unspecified